Paediatrics, Psychiatry and Psychoanalysis

Through counter-transference to case management

Adrian Sutton

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135070250
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería pedriática

How do children and parents shape clinical practice? How can clinicians learn from the impact of their patients upon them? How do we recognise if health care practices are adversely affecting health care?

Children's health problems can place enormous strain on both children and their families. Whether symptoms are acute or chronic, assessment and treatment can be confusing and frightening even when the illness itself is not dangerous. Understanding the impact of illness on emotions, relationships and development is an essential part of providing good health care services. For health care professionals it is necessary to understand how their clinical practice affects their patients and how this reciprocal relationship shapes good or bad practice.

Introducing key psychoanalytic concepts Adrian Sutton illustrates through detailed clinical studies how psychoanalytic theory can be applied in a health care setting involving children and their families. Paediatrics, Psychiatry and Psychoanalysis specifically describes the impact of the patient on the professional, how conscious and unconscious elements need to be taken into account, and to what extent these can influence practice enhancing diagnostic and therapeutic treatment.

Paediatrics, Psychiatry and Psychoanalysis is an exploration of the central importance of the patient-doctor relationship and how the psychodynamics of this relationship are crucial in providing information that can aid treatment. It will be of interest to child mental health professionals – psychoanalysts, psychotherapists, psychiatrists, psychologists, nurses, paediatric practitioners and those working in social welfare and educational settings.

1

KEY CONCEPTS FROM PSYCHOANALYSIS

I'd rather feel stupid than be ignorant.¹

Relationships evoke familiar and unfamiliar feelings. They cause people to act in characteristic or uncharacteristic ways. They shape and are shaped by what is spoken and unspoken, what is realised and what is unrealised. They may bring out the best or the worst in people.

Relationships occur in contexts which can shape how people think, feel and act. Context facilitates or inhibits the emergence of particular forms of relationships. In turn, different forms of relationship and context sanction or prohibit particular actions. The patterns which emerge create the possibility for a variety of thoughts or feelings to arise or fail to arise.

Patient and professional

Codes of practice provide a framework for practice which assist patients and professionals in knowing what it is reasonable to expect from the relationship. They describe principles which guide the range of behaviour which is acceptable from the professional but what cannot be codified is the range of thoughts and feelings which may accompany interactions. An essential part of professional training and continuing practice is learning to recognise these thoughts and feelings and to ensure they do not compromise the ability to fulfil the professional role.

Transference

Psychoanalysis emerged from the work of Sigmund Freud and Josef Breuer who explored the place of psychological trauma in producing symptoms of impaired physical functioning. Their paths separated because of differences of opinion about theory and practice. As Freud developed his approach, he found that particular patterns arose in the relationships with patients. His patients' experiences of him did not accurately reflect the person he thought he really was. When he reflected on their reports of their earlier, most important relationships he concluded that they were experiencing him in just the same way as they had experienced these key people at particular stages of their lives. He named this phenomenon transference to reflect the transposition of thoughts and feelings from earlier relationships to the current relationship with him:

We mean a transference of feelings on to the person of the doctor, since we do not believe that the situation in the treatment could justify the development of such feelings. We suspect, on the contrary, that the whole readiness for these feelings is derived from elsewhere, that they were already prepared in the patient and, upon the opportunity offered by the analytic treatment, are transferred on to the person of the doctor.

(Freud S. 1927: 194)

Crucially Freud's refections led him to recognise and accept what was happening for what it was. He did not take it personally, regardless of whether it was complimentary or denigratory. It was a response to him in this particular professional role and emerged because of the particular form and structure of this relationship.

Initially Freud viewed transference as an obstruction to the ‘real’ work of the psychoanalytic process. His approach was more akin to an intellectual, archaeological process, i.e. the identification of the underlying events, experi-ences, impulses and their buried roots in infancy and childhood. However as psychoanalytic practice and theory evolved it became apparent that, rather than being an obstacle, this resistance was a mechanism through which thera-peutic change could occur. The peculiar form of the relationship with the psychoanalyst, with its regularity, physical arrangement and disciplined focus on its aims and objectives, produced a particular constellation. The difficulties from the original relationship were recreated and re-enacted in the consulting room: Freud called this transference neurosis. However, this was not an arcane exercise in creating a false world for its own sake. What became apparent was that the symptoms which had led the patients to seek help were significantly contributed to by these same processes operating in their everyday relation-ships. This was leading to distress and dysfunction.

The realisation of the occurrence of transference, its acknowledgement with the patient and the identification of its effects in their everyday life became a fundamental component of the analyst's work with and for the patient. Juxtaposing historical, current and therapeutic relationships, with all their twists and turns, became a means of assisting patients to become less constrained by the adverse impact of the underlying confusions, fears and longings which they brought to relationships. Malan (1979) later captured this in his ‘Two Triangles’.

By respecting the intensity and immediacy of the patient's experience of the analyst and simultaneously accepting the essential expendability of the analyst in their ongoing life, the analyst could provide an opportunity for problems to be worked through in the transference. What also became apparent was that the focus of the therapeutic process could lead to an intensity of experience in the patient which could not be contained in the consulting room. It spilled over into their everyday relationships, for example, causing an apparently inappropriate or understandable reaction to something or someone. This is the origin of the phrase acting out which originally meant the enactment of transference issues outside of the consulting room. It subsequently came into use in wider circles and has become corrupted simply to mean bad or unwanted behaviour.

Wider application of psychoanalytic ideas made it apparent that trans-ference processes are manifest in wider personal and professional relationships outside the psychoanalytic consulting room. They occur in the general psychiatric setting with clinicians and other professionals.

Clinical example 1.1

Mrs J was seen as part of the crisis management after her son attempted suicide. At first she came across as defensive and agitated, giving an impression of hostility. However, as the consultation progressed, she began to appear more at ease and the assessment developed the sense of a co-operative venture about her son's welfare. As part of the routine assessment she gave a detailed description of her experiences of abuse at the hands of her parents and other adults. She also told me that she was worried that she was going to be criticised now for what was happening with her son.

Her son had remained on the ward over the weekend and I arranged to see her again three days later. When I returned, Mrs J was again hostile and ‘prickly’. It seemed to me that I had again become a threat to her. I thought Mrs J had probably unconsciously experienced my absence during the weekend as a failure in care and protection and that this was resonating with her childhood experiences of abuse. Just as she had had to rely on her parents, trying to trust that they would behave in her best interests, she had tried again with me and I had absented myself when she was in need.

I would usually have reserved interpretation of an acute transference process such as this to the situation of a patient established in psycho-therapy. However, the intensity of her reaction, and its potential to severely undermine her son's care, made me decide to respond by inter-preting what I thought what was happening.

I told Mrs J that I thought something had changed dramatically in her feeling about me: on Friday she had found me supportive, but now she felt the opposite. I told her I thought she was again expecting to be treated badly by me, just as she had been by other people when she was a child. I explained that I thought these things had become mixed up and that she was confusing me with the people who had abused her. Although there was no further specific discussion of this, her demeanour changed and we were able to re-engage around the needs of her son.

Transference processes can be conceptualised as one of the forms of illusion inherent in the human condition. the misattributions which constitute transference may not hamper efforts to live a reasonable life but, if they do, a variety of problems can arise for the individual himself and perhaps for others. Disillusionment can help people establish or re-establish a better foundation for their relationships. This may carry with it the sense of loss and sadness which is conveyed by the everyday use of the word as well as being freed from a burden of frustration, expectation and demand. It is useful to think of this as a dual process of ‘de-illusionment’, becoming liberated from the power of its enchantment, to separate this from these emotions.

Countertransference

Freud (Freud S. 1927: 517) emphasised the central importance of practi-tioners being aware of transference and taking it fully into account in their professional responses: ‘the transference is a dangerous instrument in the hands of an unconscientious doctor’. It is a complex and demanding process.

There is an inevitable paradox in the analyst's task of using an under-standing of transference. Patients evoke thoughts and feelings in the analyst which cannot be other than their own experiences however familiar, unfamiliar, unexpected or alien they may feel. The analyst has to be able to accept these as her own, allowing of what it may mean about herself. She must also be able to consider it impersonally, something which may have been evoked in any analyst simply by being that particular patient's analyst at that time in his life and at that stage of the treatment. This is the countertransference. It may be experienced in working with children and adolescents even though they are still in the immediacy of the formation and transformation of the relationships which will be identified in psychoanalytic work with adults.

The psychoanalyst has to be capable of occupying two positions, consid-ering both what she brings to the situation and what her patient brings. The former requires the development and maintenance of a particular form of reflective practice (see e.g. Mann et al. 2007: 595–621) to recognise the patterns of relating and responding which are characteristic of her. These may arise because of her own earlier life, or perhaps particular current issues, preoccupations or interests. They may be general responses or issues which arise for the particular practitioner with particular types of patients. It may not always be possible to take and maintain both positions simultaneously. The consequence can be the counterpart of a patient ‘acting out [in the trans-ference]’, ‘acting out in the countertransference’.

The same discipline is needed in the application of psychoanalytic ideas across different settings.

Clinical example 1.2

Mrs T was attending the clinic with her toddler daughter, Lisa, because of problems in their relationship. After a few sessions, she began to tell me about her own severe problems in adolescence which resulted in inpatient psychiatric treatment. She described her battles with the staff and her parents. She told me that her parents had lied to staff at times. If she protested about this she was never believed: her protestations were seen as evidence of her disorder.

I had a special interest in Mrs T's adolescent difficulties and their later effect on parenting. As the Parent-infant therapy became more robustly established, I asked Mrs T if she would mind if I looked at her psychiatric records. She agreed without hesitation but I immediately felt and thought that I had made a mistake. The request had come from my own interest. Even though I had given considerable thought to it, it was not directed by a properly reasoned decision that this would be of benefit to Lisa and her mother. On refection I realised that to obtain and read the notes would raise again an issue of who would be believed – Mrs T or the ward staff? I was recreating a situation and dynamic from her past relationships with professionals.

I did not obtain the notes. When I next saw her, I told her that I had not requested the notes because I thought I had made a mistake in asking. I apologised and explained why I thought I had been wrong. Mrs T told me that although she had felt free in giving consent, she had found herself feeling extremely anxious coming for this session. She was worried that I might have seen the notes and changed my view of her. We discussed this further before re-establishing the focus on the relationship between her and Lisa.

In the first clinical example, the ability to articulate the transference process in an authoritative but non-authoritarian manner was critical in re-establishing the therapeutic relationship. Mrs T (whose story will be considered in more detail in Chapter 4) required something similar. My error did not fundamentally undermine the therapeutic process because I recognised and acknowledged it. It became a reference point with Mrs T, giving her an experience of me as someone upon whom she was relying for help who accepted his own limita-tions and ‘realised the error of his ways’ in stark contrast to her childhood experiences. Winnicott (1963a) specifically comments on how there will be inevitable failures and that these are sometimes the route through which patients may find the means to manage things better themselves. His comment is not a call to complacency but an acknowledgement of the challenges faced and the need to be realistic about one's own abilities.

A fundamental tenet of this book is that awareness of transference and countertransference and taking them into account in professional responses will act at least to minimise the disservices we might otherwise do and at best significantly enhance our usefulness.

‘Who's in charge’ or ‘What's in charge’?

When transference was first recognised it was viewed as a resistance to therapy in the patient. But what are the implications of using the word resistance? It may sound as if there is a deliberate, wilful intention on the part of patients to prevent progress in therapy. It implies that the patient simply wants to thwart or oppose the analyst. If this is truly the case, then the analyst needs to re-consider whether there is common purpose in the endeavour (i.e. a therapeutic alliance) or reflect on whether she has misunderstood or been mistaken in her particular approach at that time.

However, ‘resistance’ in this context does not indicate that wilfulness, in the sense of a free choice, is operating. Action may clearly be emanating from the patient but we cannot assume that they are ‘deliberately’ choosing a particular course of action or that they are necessarily aware of what they are doing. Even if they are aware, they may not understand why, nor, if only for that particular moment, be able to resist doing it.

Rather than the question being ‘Why are they doing this?’ we have to ask ‘What is making this happen?’ We need to consider that some other part of the patient's make-up, of which they are not aware or, at least, over which they cannot take charge, is significantly contributing to what is happening. Freud formulated these concepts in two complementary models. The potential for either unconscious or conscious influences to be significant determinants of personal experience and action is described in the Topographical Model. The idea that despite our best efforts or intentions different aspects of ourselves can take charge of our actions is formulated in his Structural Model (id, ego and super-ego) (Freud S. 1933 [1932]).

The psychoanalytic treatment situation is...